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What is a referral?
When PCM/provider places a request to send a member to a specialist
What is an Authorization?
when a PCM/Provider places a request to complete a service/provide DME for a member
How many visits is an Evaluate and Treat referral?
6 - 1 initial visit and 5 follow up visits
How many Visits is a Second Opinion referral?
2 - 1 initial and 1 follow up
What is a CPT code?
Current Procedural Terminology - a code for a service a provider is placing on an auth/claim
What is an ICD-10 code?
Diagnosis code - a code for a symptom or 'diagnosis' a patient had.
When you look in the RADS tool or benefits, if something is Limited, does it need an auth/referral?
Yes. It MAY be covered with an auth/referral if it shows as limited.
When you look in the RADS tool or benefits, if something is Covered, does it need an Auth/Referral?
No. It is covered and does not need any extra steps
When you look in the RADS tool or benefits, if something is Not Covered, does it need an Auth/Referral?
No, if it is not covered, we do not cover it at all/it may be on the exclusions list.
True or False: Referrals do not have an end/void date.
False: Episode of Care: •6 months for ADSM •365 days for Everyone Else
True Or False: DHA-QL covers LOD claims/Auths/Referrals
False: DHA- GL as in Defense Health Agency - Great Lakes
True or False: EOPs go to the Provider
True: Explanation of Payment
What is an EOB?
Explanation of Benefits sent to the member about their visit/breakdown of their doctors visit
Who determines Eligibility?
BOS: Branch of Service
What Reports Eligibility?
DEERS
